The study, conducted at Cerrahpaşa Medical Faculty in Istanbul and approved by the institutional review board there, retrospectively evaluated the clinical and follow-up records of patients diagnosed and managed at the centre over a ten-year period. Engin performed the skin biopsies, diagnosed and treated the patients, and led the manuscript; Yildirim assisted with follow-up and drafted the text; Erkoc classified treatments and staging and analysed the data. The work was carried out in accordance with the Declaration of Helsinki, and the authors report no conflicts of interest. As is typical for retrospective cohort analyses of rare lymphomas, the value of the dataset lies less in dramatic new findings than in the granular picture it paints of how one busy dermatology service handles a diagnostically treacherous disease over time.

Technically, mycosis fungoides belongs to the primary cutaneous lymphomas, a family of extranodal non-Hodgkin lymphomas that arise in the skin rather than in lymphoid organs. The current diagnostic framework is anchored by the 2018 update of the WHO-EORTC classification, which separates indolent entities such as early-stage mycosis fungoides from aggressive ones such as Sézary syndrome, the leukemic variant characterised by widespread erythroderma, circulating malignant T cells and a markedly worse prognosis. The International Consensus Classification of mature lymphoid neoplasms, published in 2022, further refined this landscape. Within that framework, mycosis fungoides follows a characteristic clinical course: patch-stage lesions progress to plaques, then potentially to tumours, and in a minority of patients to visceral involvement. Most patients, however, never advance beyond the early stages, which is why accurate staging at diagnosis is the single most important prognostic exercise.

That staging depends on a synthesis of clinical, histopathological and, where indicated, molecular data. Skin biopsies are examined for epidermotropism, the migration of atypical T lymphocytes into the epidermis, and for the formation of Pautrier microabscesses, small clusters of these cells that are highly characteristic though not always present. T-cell receptor gene rearrangement studies can demonstrate clonality, distinguishing a malignant population from a reactive infiltrate, but early lesions may lack convincing clonal evidence, forcing clinicians to repeat biopsies over months or years. Blood tests assess for Sézary cells, and in advanced cases, imaging and lymph node biopsy complete the tumour-node-metastasis-blood staging algorithm. The Istanbul study reflects this layered diagnostic process, with the corresponding author personally performing and interpreting the skin biopsies that anchored each patient’s diagnosis.

One of the best-documented problems in the field is diagnostic delay. A frequently cited Danish study by Skov and Gniadecki found that the histopathological diagnosis of mycosis fungoides is often delayed, with patients carrying the disease for years before a biopsy confirms it, partly because early histology is subtle and mimics spongiotic or psoriasiform dermatitis. Every additional year of misdiagnosis represents deferred access to skin-directed therapy and prolonged uncertainty for the patient. A ten-year single-centre dataset is precisely the kind of evidence that quantifies this burden in a specific population, and the Turkish authors frame their work explicitly as an evaluation of clinical and follow-up data, the raw material from which such delays and their consequences can be measured.

Treatment for mycosis fungoides is stage-adapted, and the European Organisation for Research and Treatment of Cancer issued updated consensus recommendations in 2023 that codify the current hierarchy. Early-stage disease is managed with skin-directed therapies: topical corticosteroids and retinoids, phototherapy with narrowband UVB for patches and thin plaques, psoralen plus ultraviolet A for thicker lesions, and localised radiotherapy or total skin electron beam therapy for more extensive or refractory cutaneous involvement. Advanced disease adds systemic options, including interferon-alpha, retinoids such as bexarotene, histone deacetylase inhibitors, antibody-based therapies and, in selected cases, allogeneic stem cell transplantation, the only treatment with potential for durable cure. Combination approaches, pairing a skin-directed modality with a systemic agent, are common in tumour-stage disease. The Istanbul team’s classification of treatments and staging across their cohort maps directly onto this algorithm and illustrates how a high-volume centre deploys it in practice.

Single-centre cohort studies of this kind occupy an important niche in rare-disease research. Randomised trials in mycosis fungoides are difficult to power because the disease is uncommon and its early stages progress slowly, so much of what is known about natural history, treatment patterns and outcomes comes from institutional series accumulated over years or decades. Previous examples include the retrospective analysis of 133 cutaneous lymphoma patients from a single Japanese centre published by Fujita and colleagues, which similarly documented presentation patterns and outcomes over a multi-year window. The Turkish dataset joins this tradition, offering a Mediterranean and Middle Eastern patient population whose demographic profile, referral pathways and treatment access may differ meaningfully from the Northern European and Japanese cohorts that dominate the literature.

The follow-up dimension of the study deserves particular emphasis. Mycosis fungoides can smoulder for decades, and late relapse or transformation to a more aggressive large-cell phenotype can occur years after apparent stability. Longitudinal data from a single centre, where patients are followed by the same diagnostic and therapeutic team, reduce the heterogeneity that plagues multi-site registries, though they also introduce the limitations inherent to retrospective design: reliance on recorded notes, potential loss of patients to follow-up, and the absence of a standardised prospective protocol. The authors’ explicit contribution statement, detailing who diagnosed, biopsied, treated, staged and analysed, underscores the continuity of care that gives such datasets their internal consistency.

For the wider scientific audience, the significance of this research letter lies in what it represents rather than in any single headline number. It demonstrates that cutaneous lymphoma care in Turkey is organised around internationally recognised classification and treatment frameworks, that long-term follow-up is feasible in a public hospital dermatology service, and that the diagnostic bottleneck remains the central challenge of the disease. It also reinforces a message that dermatologists have been repeating for years: persistent, treatment-resistant or unusually distributed skin lesions in adults warrant a low threshold for biopsy and, when histology is equivocal, serial re-biopsy and specialist referral. Earlier recognition will not change the biology of mycosis fungoides, but it moves patients into appropriate surveillance and stage-appropriate therapy sooner, which matters for quality of life and, in the minority who progress, for survival.

The study is available as a research letter in volume 318 of the Archives of Dermatological Research, and its full clinical tables and figures are accessible through the journal. As genomic profiling, targeted immunotherapies and biomarker-driven risk stratification enter the cutaneous lymphoma field, datasets like this one, grounded in a decade of unbroken clinical contact with patients, will serve as the historical baseline against which the next generation of diagnostics and treatments is judged. For now, the Istanbul experience stands as a reminder that in rare lymphomas of the skin, the most powerful clinical instrument remains the patient chart kept faithfully over many years.

Subject of Research: A 10-year single-centre retrospective evaluation of clinical presentation, staging, treatment and follow-up in patients with mycosis fungoides, the most common cutaneous T-cell lymphoma.

Article Title: Evaluation of clinical and follow-up data in patients with mycosis fungoides: a 10-year single-centre experience

Article References: Engin, B., Yildirim, G., & Erkoc, Y. C. (2026). Evaluation of clinical and follow-up data in patients with mycosis fungoides: a 10-year single-centre experience. Archives of Dermatological Research, 318(1), Article 449. https://doi.org/10.1007/s00403-026-04943-7

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04943-7

Keywords: mycosis fungoides, cutaneous T-cell lymphoma, dermatology, WHO-EORTC classification, diagnostic delay, skin biopsy, staging, skin-directed therapy, Sézary syndrome, retrospective cohort study, Istanbul, long-term follow-up

Bortezomib is not a new molecule. The drug, best known for its role in treating multiple myeloma and mantle cell lymphoma, works by blocking the proteasome, the cellular machinery that degrades damaged or unwanted proteins. When proteasomal degradation grinds to a halt, misfolded proteins accumulate, stress pathways ignite and cells that cannot cope are pushed into programmed death. Earlier clinical and laboratory observations had suggested that bortezomib has activity against CTCL, but the molecular wiring behind that activity had never been fully mapped. The research team, led by Kirti S. Prabhu and Shahab Uddin, set out to answer two linked questions: does bortezomib modulate SKP2-associated cell-cycle regulation in CTCL cells, and can it be combined effectively with the platinum chemotherapy drug cisplatin?

To do this, the investigators used two well-characterized human CTCL cell lines, H9 and HH, exposing them to escalating concentrations of bortezomib and measuring viability with cell counting assays, then probing the consequences with fluorescence imaging and flow cytometry. The drug proved remarkably potent. The 24-hour concentration that killed half the cells, the IC50, was just 5.25 nanomolar in H9 cells and an even lower 1.82 nanomolar in HH cells. Values in the low nanomolar range are notable because they sit comfortably within concentrations achievable in clinical practice, lending translational weight to the laboratory findings. The team then asked what kind of death the cells were dying, and the answer was unambiguous: apoptosis, the orderly suicide program that cancer cells often manage to evade.

The apoptotic signature emerged at several levels simultaneously. Flow cytometry revealed a rising sub-G0/G1 population, a classic hallmark of cells with fragmented DNA, alongside an increase in Annexin V-positive cells, which flag the externalization of phosphatidylserine, an early molecular signal of apoptosis. Immunoblotting showed activation of the caspase cascade, the proteolytic machinery that executes cell death: caspase-8, caspase-9 and caspase-3 were all cleaved into their active forms, and PARP, a DNA repair enzyme that caspase-3 slices as a finishing blow, was cleaved as well. The intrinsic, or mitochondrial, arm of apoptosis was clearly engaged, because the ratio of the pro-death protein Bax to the pro-survival protein Bcl-2 increased, and the mitochondrial membrane potential collapsed, a depolarization event that releases apoptogenic factors from the intermembrane space into the cytosol.

To confirm that this death was truly caspase-dependent, the researchers pre-treated cells with z-VAD-FMK, a broad-spectrum inhibitor that shuts down all caspases. The inhibitor significantly blunted bortezomib-induced apoptosis, demonstrating that the caspase cascade is a functional component of the drug’s cytotoxicity rather than a bystander effect. That finding matters because it anchors bortezomib’s action in a defined, druggable death pathway, one that can be monitored and potentially amplified by rational drug combinations.

Perhaps the most mechanistically revealing part of the study concerns reactive oxygen species, or ROS. Bortezomib treatment increased both cellular and mitochondrial ROS and simultaneously depleted intracellular glutathione, the cell’s principal endogenous antioxidant buffer. This double hit, more oxidants and less antioxidant capacity, creates a state of oxidative stress that damages mitochondrial membranes and feeds the apoptotic circuit. The causal contribution of ROS was tested with N-acetyl-L-cysteine, a glutathione-replenishing antioxidant. When NAC was present, bortezomib’s disruption of the cell cycle, its induction of apoptosis and its activation of caspases were all partially reduced. In other words, oxidative stress is not the whole story, but it is a genuine upstream driver of the cytotoxic program, and the partial rescue suggests that bortezomib kills CTCL cells through converging ROS-dependent and ROS-independent routes.

The study also connected bortezomib’s effects to cell-cycle control, an area where CTCL cells are particularly vulnerable. The team observed a marked suppression of SKP2, S-phase kinase-associated protein 2, an E3 ubiquitin ligase component famous for tagging the cyclin-dependent kinase inhibitors p21 and p27 for destruction. When SKP2 falls, its targets accumulate, and that is exactly what the researchers documented: levels of p21 and p27 rose while the cyclin-dependent kinases CDK4 and CDK6, which drive cells through the G1 checkpoint, declined. This SKP2-p21/p27 axis functions as a brake on proliferation, and bortezomib effectively re-engages that brake. Because SKP2 is an oncogenic driver in many lymphoid malignancies, its suppression offers a candidate pharmacodynamic vulnerability, a measurable molecular endpoint that clinicians could track to confirm that the drug is hitting its intended target in patients.

Combination therapy was the final piece of the puzzle. Platinum-based agents such as cisplatin are mainstays of oncology, but their use in CTCL is limited by toxicity and modest durable benefit. Using the Chou-Talalay method, a widely accepted mathematical framework for quantifying drug interactions through the combination index, the researchers tested whether bortezomib and cisplatin act cooperatively. At selected dose pairings, bortezomib enhanced cisplatin-induced loss of viability and apoptosis, and the interaction was strongly synergistic at 5 nanomolar bortezomib combined with 10 micromolar cisplatin. Synergy means the combination kills more cells than the sum of the two drugs acting alone, a property that could, in principle, allow lower doses of each agent and a narrower toxicity profile. The mechanistic logic is plausible: bortezomib’s ROS generation and caspase priming may lower the apoptotic threshold that cisplatin-induced DNA damage must cross to trigger cell death.

The authors are careful to frame these results as a foundation rather than a clinical verdict. All of the experiments were performed in established cell lines, and the study’s own conclusions call for validation in primary CTCL samples from patients and in in vivo models before the strategy can move toward the clinic. That caveat is standard and appropriate, yet the work still carries real significance. It converts a clinical observation, that bortezomib has activity in CTCL, into a mechanistic account involving ROS accumulation, glutathione depletion, mitochondrial depolarization, caspase activation and SKP2 pathway suppression, and it nominates a specific synergistic drug pairing for further testing. For a disease with limited durable options in its advanced stages, that combination of mechanistic depth and translational direction is exactly the kind of progress that translational medicine aims to deliver, and it gives CTCL researchers a clear set of molecular signposts to follow in the next phase of preclinical and clinical evaluation.

Subject of Research: Proteasome inhibitor bortezomib-induced ROS-dependent mitochondrial apoptosis and SKP2 signaling suppression in cutaneous T-cell lymphoma cells

Article Title: Bortezomib induces ROS-dependent mitochondrial apoptosis and suppresses SKP2 signaling in cutaneous T-cell lymphoma cells

Article References: Bortezomib induces ROS-dependent mitochondrial apoptosis and suppresses SKP2 signaling in cutaneous T-cell lymphoma cells. (n.d.). https://doi.org/10.1186/s12967-026-09039-4

Image Credits: AI Generated

DOI: 10.1186/s12967-026-09039-4

Keywords: cutaneous T-cell lymphoma, bortezomib, SKP2, reactive oxygen species, mitochondrial apoptosis, caspases, p21, p27, cisplatin, proteasome inhibitor, glutathione, drug synergy

The trial compared 0.05 percent clobetasol propionate ointment, one of the strongest topical steroids in clinical use, with 0.1 percent tacrolimus ointment, a calcineurin inhibitor best known for treating atopic dermatitis. Twenty patients received each treatment. The question matters because early-stage mycosis fungoides is highly treatable with skin-directed therapies, yet the ideal first-choice agent has remained contested. Topical steroids are cheap, familiar, and fast, but long-term use carries the familiar toll of skin atrophy, striae, telangiectasia, and taper-dependent relapse. Tacrolimus offers a steroid-sparing alternative that suppresses T-cell activation without thinning the skin, but direct comparative evidence against clobetasol in lymphoma patients has been almost nonexistent until now.

On raw clearance rates, the verdict was lopsided. In the clobetasol group, 95 percent of patients achieved a complete clinical response, meaning their lesions resolved entirely, and the remaining 5 percent achieved a partial response. In the tacrolimus group, by contrast, only 60 percent reached complete clearance and 20 percent a partial response. The median time to complete response also favored the steroid, at two months versus three and a half months for tacrolimus, although that timing difference did not reach statistical significance. For clinicians and patients alike, the message of the first analysis is straightforward: clobetasol clears early patches and plaques faster and more often.

But the story changed when the researchers followed patients forward in time. Among those who achieved complete clearance, relapse occurred in 63.2 percent of the clobetasol-treated patients compared with just 25 percent of those treated with tacrolimus, a difference that approached but did not reach conventional statistical significance. Kaplan-Meier survival analysis, which tracks how long patients remain disease-free over months and years, showed a trend toward longer relapse-free survival in the tacrolimus group, with a log-rank p-value of 0.060. In a study of only forty patients, trends of this size are tantalizing rather than definitive, but they hint at a trade-off that clinicians have long suspected: steroids win the sprint while tacrolimus may hold ground longer in the marathon.

The biology behind that trade-off is worth unpacking. Mycosis fungoides is driven by clonal malignant T lymphocytes that home to the skin, and both drugs attack the inflammatory machinery these cells depend on, but by different routes. Clobetasol binds intracellular glucocorticoid receptors, broadly repressing transcription of inflammatory cytokines and inducing apoptosis in immune cells, a blunt but powerful instrument. Tacrolimus inhibits calcineurin, a phosphatase essential for activating the transcription factor NFAT in T cells, thereby blocking interleukin-2 production and T-cell proliferation with far greater selectivity. Because the steroid suppresses inflammation indiscriminately, it clears lesions dramatically, but once therapy stops or is tapered, the underlying malignant clone may rebound quickly. Calcineurin inhibition, gentler and more targeted, may leave residual disease control in place even as visible lesions fade more slowly.

Safety considerations sharpen the clinical calculus further. Prolonged use of super-potent steroids on thin skin, on the face, or in folds produces atrophy, striae, and secondary infection, and mycosis fungoides frequently affects these vulnerable sites and demands years of intermittent treatment. Tacrolimus ointment does not cause skin thinning, which is precisely why dermatologists have proposed it as a steroid-sparing option, and earlier work including a phase 2 trial of the related calcineurin inhibitor pimecrolimus published in The Lancet Haematology in 2022 demonstrated meaningful activity and tolerability in early-stage disease. One historical concern, a theoretical lymphoma risk from systemic absorption of calcineurin inhibitors, has been substantially allayed by large cohort studies such as the JOELLE investigations, which followed tens of thousands of users and found no convincing increase in lymphoma incidence, and pharmacokinetic studies showing minimal systemic exposure when tacrolimus is applied to intact skin.

The Istanbul team’s findings also sit within a growing evidence base for topical therapy in this lymphoma. Zackheim’s foundational work established patch-stage mycosis fungoides as responsive to potent topical corticosteroids, and a 2025 comparison from the same Turkish group, published in the Brazilian Annals of Dermatology, found clobetasol competitive with oral bexarotene in early disease. What has been missing is exactly the kind of direct steroid-versus-calcineurin-inhibitor comparison this study provides, even in retrospective form. The authors themselves caution that comparative data on topical therapies remain limited and that calcineurin inhibitors have been proposed as steroid-sparing alternatives largely on theoretical and indirect grounds.

The study’s limitations deserve honest weight. Forty patients divided into two groups of twenty, treated retrospectively rather than randomized, leave ample room for selection bias, confounding by disease severity or anatomical site, and underpowered statistics. Relapse definitions and follow-up duration are critical in a disease whose natural history is measured in decades, and differences that miss significance at p-values just above 0.05, as several here do, could easily prove real in a larger cohort or dissolve into noise. The authors do not claim that tacrolimus prevents relapse; they report trends. Still, in rare diseases, randomized trials are notoriously difficult to populate, and carefully collected comparative cohort data like this often guides practice for years before definitive evidence arrives.

For patients, the practical takeaway is a conversation rather than a prescription. Someone with extensive thin plaques on the face or flexures, or a history of steroid-induced skin damage, may reasonably begin with tacrolimus, accepting slower clearance and a somewhat lower chance of complete response in exchange for durability and skin preservation. Someone with thicker, widespread plaques and a need for rapid control may start with clobetasol, then consider rotating to or maintaining with a calcineurin inhibitor to hold the gains while sparing the skin. The pattern in this data, fast clearance with higher relapse on one side and slower, stickier remission on the other, maps neatly onto that sequential strategy, which many dermatologists already employ empirically.

What happens next is the familiar rhythm of clinical oncology: these findings need prospective confirmation, ideally in a randomized trial with standardized response criteria under the current ISCL-EORTC staging framework, longer follow-up to truly characterize relapse-free survival, and enough patients to convert suggestive p-values into conclusions. Until then, the Istanbul study earns its place as one of the few direct comparisons of the two most accessible topical treatments for early mycosis fungoides, and it reframes the question clinicians ask at the bedside. It is no longer simply which ointment clears the skin, but which ointment keeps it clear, and the answer may be that the humble immunomodulator cream, long relegated to second-line status, deserves a more prominent seat at the table for carefully selected patients facing this indolent lymphoma.

Subject of Research: Comparative efficacy of topical corticosteroid versus calcineurin inhibitor therapy in early-stage mycosis fungoides

Article Title: Comparison of the efficacy of topical 0.05% clobetasol propionate and topical 0.1% tacrolimus in the treatment of early-stage mycosis fungoides

Article References: Comparison of the efficacy of topical 0.05% clobetasol propionate and topical 0.1% tacrolimus in the treatment of early-stage mycosis fungoides. (n.d.). https://doi.org/10.1007/s00403-026-04958-0

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04958-0

Keywords: mycosis fungoides, cutaneous T-cell lymphoma, clobetasol propionate, tacrolimus, topical therapy, dermatology, relapse-free survival, calcineurin inhibitors, skin-directed treatment, clinical research, Comparison, efficacy